Details about you - continued
How would you describe your ethnic origin?
Please tick most appropriate / 
White / A / British
B / Irish
C / Any other White background
Mixed / D / White and Caribbean
E / White and Black African
F / White and Asian
G / Any other mixed background
Asian or British Asian / H / Indian
J / Pakistani
K / Bangladeshi
L / Any other Asian background
Black orBlack British / M / Caribbean
N / African
P / Any other Black background
Other Ethnic Groups / R / Chinese
What is your FIRST language?
Please tick most appropriate
 /  /  / 
Akan/ Ashanti / Flemish / Korea / Spanish
Albanian / French / Kurdish / Swahili
Amharic / Gaelic / Luganda / Swedish
Arabic / German / Malayalam / Taglog/Filipino
Bengali/sylheti / Greek / Mandarin / Thai
Brawa/Samali / Gujarati / Norwegian / Turkish
Cantonese / Hakka / Polish / Urdu
Creole / Hausa / Portuguese / Vietnamese
Dutch / Hebrew / Punjabi / Welsh
English / Hindi / Russian / Yoruba
Ethiopian / Igbo/Ibo / Serbian/Croatian / Other(please state)
…………………………
Farsi/Persian / Italian / Sinhala
Finnish / Japanese / Somali

Date Form Completed…………………………

HARBOURSIDE

FAMILYPRACTICE

New Patient Health

Questionnaire

Welcome to the practice

We would be grateful if you could take the time to complete the questionnaire so that we can make your medical records more accurate.

If you are a new patient you will also have received your personal invitation to attend for a New Patient Health Check.

We would be grateful if you please hand this form to the Receptionist.

Please note the following:

  • Please read the questions overleaf and complete as fully as possible
  • If you are on regular medication, you will need to make an appointment with a doctor before a repeat prescription can be issued
  • If you have any outstanding hospital appointments please contact the hospital and advise them that you have changed your doctor, name and address (if applicable)

Please turnover to complete the form.

Details about you

Name……………………………………………………………………………

Date of Birth……………………………………………………………………

Home Phone Number…………………Work Phone Number ……………

Mobile Phone Number………………………………………………………..

Are any other members of your household registered with us?......

…………………………………………………………………………………..

What school do you attend? (If applicable)…………………………………

Next of Kin

Name……………………………………………………………………………

Their Relationship to you……………………………………………………..

Their Contact Phone Number……………………………………………….

Are you responsible for someone’s care? Yes No

A ‘Carer’ is a person of any age who has caring responsibilities for a spouse, relative, friend or neighbour.

What is your:

Height………………………..Weight……………………

How would you rate your exercise routine in an average week? (Please tick one)

No exerciseMildModerate Strenuous

Are you allergic to any medicines, tablets or other substances?Yes / No

If yes, please give details……………………………………………………………………….…

……………………………………………………………………………………….………………...……

If female, do you have a coil fitted? Yes No

If yes, please state date fitted…………………………………

What is your smoking status?

 /

Please tick ONE option that most appropriately describes your status

Never Smoked Tobacco
Ex-Smoker
Current Smoker

If you do smoke we would like to encourage you to consider giving up smoking. If you feel you would like to stop smoking and would like our support, please see one of our receptionists and ask to be added to the support to stop smoking clinic list.

History of conditions

Do you, or any members of your immediate family (parents, brother, sister) suffer from any of the following conditions?

You?
(Please tick) / Family Member?
(Please state which member(s) of your family)
Diabetes

Strokes

Heart Disease (please state what typeHeart Attack, Angina, Heart Failure orAtrial Fibrillation
Respiratory Disease(please state type i.e. Asthma or COPD)
Cancer(please state type)
High Blood Pressure
Other Major Illness (please specify)